New

Utilization Review Manager - Remote - Faulkner

Brigham & Women's Faulkner Hospital
United States, Massachusetts, Boston
1153 Centre Street (Show on map)
Nov 03, 2025
The Utilization Review Manager performs the six essential activities of Case Management: Assessment Planning Implementation Coordinating Monitoring Reassessing Essential Functions -Perform utilization review to evaluate for the appropriate level of care and fax all insurance reviews timely to prevent denials. -Collaborate with patient/family and interdisciplinary team to assess for appropriate discharge needs. -Place and implement all aspects of referrals to all levels of post-acute care in 4 Next. -Online documentation of interaction with the patient, family, and interdisciplinary team. -Interact with various third-party payers on a daily basis. Fax clinical in payor communication to the right insurer with the right fax number in the right time frame. -Refer cases not meeting the appropriate level of care to the Physician Advisor or EHR. -Review for Observation status and make changes as needed. Accurately facilitate all documentation needed for Medicare status change from inpatient to observation (code 44). -Perform and monitor for quality issues and document in R.L. solutions. -Provide the patient or family member with a copy of the Important Message. -Provide to the patient or representative the Observation Notification letter. -Provide to the patient representative the Acknowledgement of disclosure, obtain choices of post-acute facilities or services, and signature. -Must be able to function independently in busy environment. -Coordinate, complete, and track all clinical denials and appeals. Bachelor's Degree Nursing required MA Registered Nurse License required 3 year of Utilization Review and Case Management experience preferred or 4 or more years of Utilization Review and Case Management experience preferred and 5 years of Acute Care Nursing required or 6 or more of Acute Care Nursing preferred Staff adheres to all I C.A.R.E. Standards. Demonstrates knowledge, skills and abilities to work with various age groups in order to provide a safe discharge plan. Must be able to provide care for the patient despite psychosocial, educational, or physical disability. Basic computer skills, experience with Excel and Word, and good computation skills. Ability to interact and communicate within a diverse community. Competent with InterQual Criteria. Competent in Utilization Review, appeals, the peer-to-peer process, and Case Management. Use critical thinking skills in all interactions and recognize the need to be solution-driven. Good negotiating skills with insurance companies and third-party payers. Performs all aspects of discharge planning to the right environment of care, timely. Proficient in the use of ECare. Brigham and Women's Faulkner Hospital, Inc. is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.